Three veterans died and nine others were injured as the result of delays in treatment for gastrointestinal cancers in the VA’s Sunshine Healthcare Network serving Florida, southern Georgia, Puerto Rico and the Virgin Islands, according to a much-anticipated VA report released Monday. The report also laid out corrective measures being taken to prevent similar problems in the future.

None of the deaths was the result of actions at the James A. Haley Veterans’ Hospital in Tampa or the C.W. “Bill” Young VA Medical Center in Bay Pines, according to the National Consult Delay Review Fact Sheet report delivered to Congress. But there were two “institutional disclosures” at the Bay Pines facility and one in Tampa, according to the report. That means that patients or their representatives were notified that the veterans were harmed during their care. The report does not provide any specifics about the level of harm, nor does it list any patient names.

Two of the deaths resulted from delays at the North Florida/South Georgia VA Health System and one was from the West Palm Beach VA Medical Center, according to the VA. Another two patient deaths in the region were determined not be related to the delays, according to the VA.

The deaths and injuries in the Sunshine Healthcare Network were from 301,000 consultations made between 2010 and 2012, according to Joleen Clark, director of the Sunshine Healthcare Network, also known as VISN 8.

Nationwide, there were 17 other deaths and 44 other patient injuries found during a VA review initiated after deaths were discovered in Georgia and South Carolina.

There were seven deaths reported by VA facilities in South Carolina, three in Georgia, two in Virginia and one each in West Virginia, Ohio, Arizona, Colorado and Iowa, according to the report.

As a result of the findings, which included a review of 250 million consultations from 1,700 VA medical centers since 1999, the VA has a better understanding of the consultation process and improved how it authorizes and monitors health consultations, said Thomas Lynch, the VA’s assistant deputy undersecretary for health for clinical operations.

The majority of the deaths nationally happened as the result of delays in 2010 and 2011 said Lynch, who could not offer a specific figure or dates.

“For any veteran to die as the result of a medical error, or be harmed, is clearly a tragedy,” said Lynch. “I think an even greater tragedy is if we don’t learn from what happened and attempt to improve systems.”

The review was of seven “high interest” consults, including gastrointestinal endoscopy, said Lynch. A systemwide review is ongoing.

One of the changes, said Lynch, is enabling the VA to have a systemwide overview of consultations and react accordingly. If there is an increase in consultations requested, managers can react by either adding more staff in the case of sustained increases or jobbing out the work to local health care systems if the increase appears temporary.

In the Sunshine Healthcare Network, officials are now reviewing any consultation older than 60 days as well as instituting an automated tool to make sure that those with immediate needs are not waiting, said Clark.

Until Monday, VA officials had refused to list all the facilities involved in the deaths and injuries. The VA also denied a Freedom of Information Act request filed by The Tribune seeking the information, which was first reported by CNN.

The issue became fodder for politicians reacting to stories and an editorial in The Tampa Tribune. First, Sen. Bill Nelson, D-Fla., then Gov. Rick Scott weighed in on the issue, with Nelson writing a letter to VA Secretary Eric Shinseki and visiting Haley, while Scott ordered the state’s Agency for Health Care Administration to inspect VA hospitals. Those inspectors were turned away from the West Palm Beach VA center last week. The VA cited patient privacy as the reason.

Scott on Monday repeated his call for the VA to let the inspectors in.

“If the VA is interested in transparency and accountability, they will open their doors to state inspectors so we can get answers about the subpar treatment our veterans are receiving,” said John Tupps, a Scott spokesman.

“I’m glad to see the VA being open,” Nelson said in an emailed statement. “At the end of the day, it’s all about giving veterans the best care.”

U.S. Rep. Jeff Miller, R-Fla., chairman of the House Veterans Affairs Committee, agreed with Nelson that getting the information out to the public was a good step. His committee has been seeking the identity of where the delays occurred since last September.

“These heartbreaking findings are just the first step VA must take in rebuilding the trust of the veterans and family members affected by these tragic delays in care,” said Miller. “In addition to swiftly putting in place reforms to ensure this never happens again, it is incumbent upon VA to reveal precisely when these deaths and injuries occurred and whether any VA employees who may have allowed veterans to fall through the cracks have been held accountable. Unfortunately, we haven’t seen any evidence so far indicating that preventable deaths at VA facilities result in serious discipline for the employees responsible.“

Before the VA could begin any disciplinary action, it first had to determine the problem and find a solution, said Carolyn Clancy, the VA’s assistant deputy undersecretary for health, patient safety, quality, and value.

“Now we can review whether any disciplinary action is warranted,” Clancy said.

Miller seemed skeptical.

“If you look at recent VA preventable deaths linked to mismanagement – in Pittsburgh, Atlanta, Columbia, S.C., Augusta, Ga., and Memphis, Tenn. – VA executives who presided over negligence are more likely to have received a bonus or glowing performance review than any sort of punishment,” he said. “What’s worse, department officials have repeatedly pointed to nondisciplinary actions such as employee retirements and transfers or bureaucratic slaps on the wrist, such as temporary written warnings, in a disingenuous attempt to create the appearance of accountability. Such semantic sleights of hand are insulting to the families of those who died, veterans seeking care at VA as well as the taxpayers who fund the department’s operations. Until department leaders take steps to ensure VA employees and executives are adequately punished rather than rewarded for mistakes, it is simply illogical to think the many problems plaguing VA will subside.”